Intergalactic Adventures in Art

Summer Camp @MAC

Monday – Friday, June 12-23, 9:30-12:30

Name of participant:Age:

Additional sibling participating:Age:

Parent/Guardian:

Phone: Cell:Email:

Home Address:

Please send your child in or with clothing they can dirty with clay, and non-washable paint or a smock

Payment: $225/2 wks MAC Members $202.50 $400/2 Siblings

$125/1 wk MAC Members $112.50

Mac offers classes for the whole family. You can purchase a family membership for $100

Receive 10% or classes and support the arts in Middletown.

Allergies or Sensitivities? Y N (if yes please list)

Emergency contacts (EM). If you are not available, who should we contact?Please include phone numbers

Pick up from camp (PU)? Who may pick your child up from Camp?

Please mark EM and/or PU as applicable below

Photo Release: MAC may take photos of my child and use these to promote MAC______

My Child may walk home on their own. _____. I release MAC from responsibilities for my child once my child has left the MAC building at the end of daily activities.

Signature of Parent/Guardian ______

Agreements and Waiver:

1.Campers are expected to follow directions, perform to the best of their abilities, and torespect others in the class. If necessary, parents will be informed of any misconduct. Theinstructor reserves the right to dismiss any student(s) from the session depending upon theseverity of the situation. In the event that removal from camp is deemed necessary, fees will be prorated and the balance returned.

2. Special Needs (physical, mental, or emotional) should be brought to the attention of theinstructor prior to beginning of class in order to provide all of our students with the most effective learning environment. All information received is strictly confidential. If special assistance is required at school, parents/guardians mustprovide similar assistance for his/her child at MAC as well, as needed.

3. Late Child Pick-up will accrue additional charges after a 10-minute grace period (unless otherwise agreed upon). It isimportant that students are picked up on time. Please call in advance if there will be any unusual delays 707-809-8118.

Waiver:The safety and well being of your child is our top priority at Middletown Art Center (MAC). MAC will not be responsible for and will be forever RELEASED from any injury(ies), claims,and/or any other liability arising from your child’s attendance and participation in programs at MAC, and/or for any lost property left behind by your child.

By signingthis waiver form, you agree to indemnify and hold harmless from any and all injury(ies), claims,causes of action, and/or any other liability arising from your child’s attendance and participation in MAC’s programs. You furtheraffirm that you understand the contents of this agreement and are free to choose not to participate in MAC’s programs. By signing this Waiver you affirm that you have decidedto allow your child to participate in programs and services provided at MAC with thefull knowledge that MAC will not be liable to anyone for personal injuries and propertydamage while at MAC.

Name/Date

Signature______

21456 Hwy 175 (at Hwy 29) 707.809.8118